The Pre-brief
The EMS crew has sent a pre-alert for a severely injured patient who will be here in about 10 minutes. The trauma pager has been activated and the team is assembling.
“Who’s running this?” the documenting nurse asks.
“I am.” comes the answer.
Everyone turns to see the new (female) trauma fellow positioned at the foot of the bed.
Someone mumbles under their breath, “Oh great…wonder if she’s gonna be a real leader here…”
The Problem
Gender bias in medicine is a very real problem, affecting all things from interpersonal interactions amongst colleagues, patient perception, academic promotion, and feedback. Team leadership remains a key skill for clinicians in acute care specialties to master but is similarly affected by gender bias. In order to overcome bias, we must show whether there actually is or is not a difference in outcomes. This is the premise of a paper recently published in JACEP Open by Rosenman et al. entitled “Does team leader gender matter? A Bayesian reconciliation of leadership and patient care during trauma resuscitations.”
The Methods
The study authors prospectively examined team leadership and patient care in ED trauma teams led by both male and female physicians. Importantly, and differently from prior work, they used Bayesian methods to evaluate the relationship of gender and both team leadership and patient care to see if there actually exists a gender-based advantage.
They performed a secondary analysis of data from a large RCT that had been performed to review the impact of simulation-based team leadership training on patient care using tape review of actual trauma resuscitations over 18 months (April 2016 to December 2017).
Tapes had the participant’s faces blurred to obscure their identity. Participants were 2nd or 3rd-year emergency medicine and general surgery residents assigned to the team leader role.Two video observations were made for each participant.
Each tape was reviewed by two independent groups of trained raters who were balanced based on their gender and were blinded to the study hypotheses. Inter-rater reliability and probability of bias were measured and accounted for.
The center had a level 1 trauma center designation with over 5000 trauma-related admissions per year.
Cases were reviewed if:
- They were led by an enrolled participant of the prior study
- The patient met trauma team activation criteria at that center
Cases were excluded if the patient:
- Was pregnant
- Was dead
- Left the ED within 5 minutes of arrival
- Had a DNR order
- Was a prisoner
- Had a nontraumatic mechanism or isolated burns
The Bayesian methodology was utilized to assess outcomes because as opposed to traditional null hypothesis testing, the Bayesian method allows summarization of the probability of ALL possible hypotheses. The full details of their analysis are in the manuscript.
The Findings
60 participants were included for a total of 120 recordings.
Team leaders, patients, and resuscitation characteristics showed no significant differences except for patient ethnicity.
When evaluating for both team leadership – there was no conclusive evidence of differences between gender of the team leader.
When evaluating patient outcomes – again there was no significant observed difference when the team leader was of either sex.
The Limitations
This is an interesting study but as always has some limitations. Primarily this was a single-center study albeit one with a high volume of trauma resuscitations. In addition, this evaluated the performance of resident team leaders. Was there any bias from the supervising physician (whose sex was not stated) which was not accounted for? Would attending-led teams have the same outcomes?
The Debrief
In this study looking prospectively at team leadership performance and patient outcomes (saying this louder for the people in the back) – there is no support for previously reported gender-based differences in team leadership.
Although our focus should be on ensuring that all our trainees (whoever they are) are educated in a manner where they are empowered to be effective and safe team members and leaders, we must acknowledge that gender issues in medicine continue to raise their ugly head…the fact that this continues to appear in the literature is a case-in-point.
Our entire team implores you to tackle this issue head-on and call it out when you see it.
